Healthcare Provider Details

I. General information

NPI: 1689047623
Provider Name (Legal Business Name): KATHLEEN MARAVILLAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2015
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1180 N TOWN CENTER DR STE 100
LAS VEGAS NV
89144-6308
US

IV. Provider business mailing address

1180 N TOWN CENTER DR STE 100
LAS VEGAS NV
89144-6308
US

V. Phone/Fax

Practice location:
  • Phone: 702-769-2781
  • Fax: 725-214-6529
Mailing address:
  • Phone: 702-769-2781
  • Fax: 725-214-6529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: